California Licensed Clinical Documentation Specialist
Job Summary
To enhance clinical documentation integrity, the full-time California Licensed Clinical Documentation Specialist will perform second-level reviews of medical records, provide expert consultation on coding and diagnostics-related groups, and lead staff training initiatives while working remotely.
Key responsibilities:
- Conduct second-level reviews of medical/health records to ensure accuracy and completeness of clinical documentation
- Collaborate with leadership to analyze data and identify trends for improving clinical documentation processes
- Develop and deliver training programs on clinical documentation improvement and coding standards
Required qualifications:
- Minimum five (5) years of experience in a leadership role related to clinical documentation improvement or integrity
- Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, or equivalent experience
- Minimum nine (9) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field
- Experience with audits and compliance management in a healthcare setting
- Proficiency in using Electronic Medical Record (EMR) systems, preferably Epic System software
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